The Fight to Save the Affordable Care Act Is Really a Class Battle

Starting to mitigate America’s yawning class divide is exactly what the ACA did. And that’s exactly what the Republican plan would undo.

March 9, 2017

A girl stands holding a sign at a rally in Denver, January 31, 2017. (AP Photo / Brennan Linsley)

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One week after Republicans introduced their controversial “repeal and replace” legislation for the Affordable Care Act, the Congressional Budget Office estimated that the bill would result in 24 million fewer people being insured by 2026, while insurers and the wealthy would be nearly $600 billion richer. “In terms of insurance coverage, it’s immoral; in terms of giving money to the rich at the expense of working families, it is indecent and wrong,” House minority leader Nancy Pelosi told reporters at a press conference. It is also out of touch with what the American people have come to expect since the implementation of the Affordable Care Act, which has sent our uninsured rate to a record low of less than 9 percent. The Obama administration was clear that the objective of the ACA was to “insure everybody, to get everybody into the health system,” as Kathleen Sebelius, the former secretary of Health and Human Services, recently explained on Meet the Press. Congressional Republicans have no such goal. “We always know you’re never going to win a coverage beauty contest when it’s free market versus government mandates,” House Speaker Paul Ryan said in response to the CBO report.

Even the most vociferous opponents of the ACA have, from the start, defended some features of the law, such as the ability of parents to keep children under the age of 26 on their insurance and the ban on refusing coverage to people with preexisting conditions. Those defenders include Republican lawmakers, who incorporated both of these widely popular features in their repeal bill. But until the bill was unveiled, what was less often defended was the ACA’s role as an instrument of social justice. At its most basic, mitigating the United States’ gaping class divide on health-care access is exactly what the ACA did. And with their proposed legislation—coming up for a full House vote as soon as March 23—that is exactly what the Republicans are trying to undo.

Prior to passage of the ACA, most low-income adults could not receive Medicaid because income-eligibility limits were downright draconian in most states—well below the current federal poverty level of $11,880 a year for an individual. In a blatant gesture of discrimination, federal law excluded non-elderly, nondisabled adults without dependent children entirely from Medicaid eligibility. How sick you were, what health crisis you were facing, did not matter. If you suffered, you suffered. If you died, you died—as an estimated 20,000 to 45,000 Americans did each year because they didn’t have health insurance. That had become the American way.

The ACA began to change that. With Medicaid expansion, the Affordable Care Act went a long way toward increasing access to health care for many of America’s forgotten poor, near-poor, and disabled. The expansion made 11 million non-elderly adults with incomes up to 138 percent of the federal poverty level ($16,394 a year for an individual) newly eligible for Medicaid, with no or very-low-cost premiums, leaving them responsible only for other nominal health-care costs. It opened the door to Medicaid for adults who had no dependent children. And it expanded Medicaid eligibility for more people with disabilities. That not only made them healthier; it also protected them from lives of forced institutionalization. Medicaid is the primary payer for the cost of long-term support services that are critical to the ability of low-income people with disabilities to live, work, and be active in the community; private insurers and Medicare provide precious little support for these or related services.

The ACA also gave a financial leg up to people who earned too much to be eligible for Medicaid but still much less than would enable them to buy private insurance independently. It enabled those with incomes from 100 to 400 percent of the federal poverty level ($11,880 to $47,520 for individuals; $24,300 to $97,200 for a family of four) to buy health insurance on the public exchanges with the aid of premium tax credits, as long as they didn’t have access to a qualified plan through an employer. An estimated 85 percent of the 11 million people who bought health insurance on the state or federal marketplaces did so with the aid of tax credits that lowered their premiums. In addition, more than 6 million of the lowest-income people—those with incomes from 100 to 250 percent of the federal poverty level—also became eligible for cost-sharing reductions, which cap out-of-pocket costs like deductibles and co-pays. All told, the ACA extended health insurance to 20 million formerly uninsured low- and moderate-income people.

While that is an enormous accomplishment, controversy attended the law from the start. The ACA introduced a slate of taxes on corporations and the wealthy to help pay for the coverage expansion—a redistribution of wealth downward. Despite the fact that many of the ACA’s features were drawn from Republican health-care proposals developed before Obama’s presidency, Republicans refused to sign on, and the law passed without a single Republican vote in favor. Major technical snafus made the inaugural sign-up for individual policies on the federal exchange a disaster. Costs rose. And with people just beyond the cutoff for Medicaid or premium subsidies being required to pay full freight for their health care, some resentment was inevitable.

In time, premiums grew an average of 22 percent, and as much as 145 percent in one location. They grew in large part because insufficient numbers of young people signed up for coverage, but also, according to Princeton University economist Uwe Reinhardt, writing in the Journal of the American Medical Association Forum, because some insurers originally underpriced premiums, perhaps anticipating volume—and because health care costs at least twice as much in the United States as in other countries. The combined amount a person could be responsible for in deductibles and co-pays with the ACA climbed as well: In 2016, the ACA capped those out-of-pocket maximums for all insurance plans on and off the exchanges at $7,150 for an individual and $14,300 for a family. (That out-of-pocket costs had never been capped before the ACA gets lost in the conversation.) Finally, the number of insurers willing to participate in the exchanges dropped precipitously in many locations, and many people could no longer find the doctors they trusted in their networks. Today, in most states, there are fewer individual-market issuers both inside and outside the exchanges than before the ACA went into effect.

An unanticipated consequence of the ACA may be a change in the American mindset about government involvement in healthcare.

But premiums on the individual market had been rising before passage of the ACA, too—up 20 percent in 2010 over the previous year. In fact, according to an analysis by Brookings Institution researchers, average premiums in the individual market actually dropped significantly upon the implementation of the ACA, even as coverage improved. Deductibles had also been on the upswing; the Kaiser Family Foundation reported that 26 percent of the people who’d bought their own insurance in 2010 faced a $5,000 or higher annual deductible. (Before the ACA, while the insurance market was not shrinking, the number of insurers offering individual policies varied widely by location, and insurers were allowed to offer expensive, limited-benefit plans that lacked key ACA protections.) And even those who weren’t on Medicaid or buying subsidized insurance benefited from the law, from such features as no-cost preventive care and requirements that insurers cover 10 essential services. But individuals who received neither Medicaid nor subsidies tended to feel like they were being left out. One Kaiser survey found that the majority of those who received a tax credit—58 percent—were more likely than those who didn’t to feel that they’d seen benefits from the law. Another Kaiser poll found that, while 50 percent of the public thought low-income people were better off under the ACA, only 27 percent thought those who bought their own health insurance were better off.

Newly eligible Medicaid recipients came in for resentment, too. In late December last year, Kaiser held six focus groups with Trump voters in three Rust Belt states (Pennsylvania, Ohio, and Michigan). Three focus groups were held with those on Medicaid, and three with those who had marketplace insurance with subsidies. Some of those with marketplace insurance—especially those battling severe health problems—saw the subsidies as insufficient and felt left behind by the law. Some, wrote Kaiser president Drew Altman in The New York Times, “saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it.” Even so, reported Kaiser, those participants felt that expanded Medicaid coverage “was important and should be retained.”

These studies suggest that the tiered structure of the ACA—in which some individuals got Medicaid, others received subsidies for exchange plans, and some still faced unmanageable health-care costs—undermined support for the program. But Americans do not want to deprive others of newly won access to care. On the contrary: An unanticipated consequence of the ACA may well be a change in the American mind-set about government involvement in health-care provision. On Medicaid, the American public’s position appears to be gradually shifting from a grudging acceptance of what has been seen as an expensive, unearned handout to a greater recognition of Medicaid’s crucial place in our social safety net. By 2005, before the ACA, nearly three-quarters (74 percent) of adults said that Medicaid was a very important program, ranking close behind Social Security (88 percent) and Medicare (83 percent). However, as the authors of a seminal review of 25 years of public opinion on health-care policy published in 2006 observed, “Medi- caid is often discussed both positively and negatively. It is seen as the country’s safety net program for low-income people, but also a program that is becoming too expensive and is threatening the stability of future federal and state budgets.” As a result, they reported, polling in 2005 found that 61 percent of respondents believed that Medicaid was in a financial crisis or had serious problems; 44 percent favored reducing the number of people qualifying for the program as one solution.

Contrast that with the responses to the ACA’s expansion of Medicaid, a program that today covers over 70 million children, adults, people with disabilities, and seniors—one in five Americans. A just-released Kaiser tracking poll found that 84 percent of those surveyed believed it was important for states that expanded Medicaid with federal funds to continue to receive those funds, including 69 percent of Republicans. While only 12 percent of Americans said they wanted to see Medicaid funding decreased, nearly half (48 percent) wanted the funding to stay the same, and more than a third (36 percent) wanted to see it increased. Faced with Republican proposals to replace open-ended Medicaid funding with limited block grants or per-capita allotments to states, nearly two-thirds of Americans (65 percent) said that Medicaid “should continue largely as it is today, with the federal government guaranteeing coverage for low-income people, setting standards for who states cover and what benefits people get, and matching state Medicaid spending as the number of people on the program goes up or down.”

Despite all of the controversy around the ACA, the most recent polls show that it has reached its highest approval level ever.

As for premium tax credits based on need, there have been complaints both from those who make too much to receive them and from those who receive them but feel they are insufficient. Still, few people favor abolishing them. A Kaiser poll in November 2016 found that 80 percent favored providing financial help to low- and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage— including 67 percent of Republicans.

But an even more telling finding emerged in January from a Pew Research Center survey. Asked if it’s the responsibility of the federal government to make sure that all Americans have health-care coverage, 60 percent of Americans said yes—the highest percentage in nearly a decade. While far more Democrats than Republicans agreed with that statement, there were significant changes by income: A majority of Republicans (52 percent) with annual incomes under $30,000 agreed with the proposition (up from 31 percent in 2016), as did over a third of Republicans making $30,000 to $74,999 (up from 14 percent in 2016). Those making the most (over $75,000) agreed the least: 18 percent, up from 16 percent the year before. Though two-thirds (67 percent) of Republicans said that the government doesn’t have a responsibility to ensure health-care coverage, more than half (56 percent) said it should continue both Medicare and Medicaid.

This picture speaks to a powerful coalition in the making. By guaranteeing coverage to a much larger share of the American public through Medicaid, and by convincing Americans of the justice implicit in the government’s providing financial assistance to those who can’t afford health insurance on their own, the ACA began to move us closer to a commitment to universal health care. While that term has become needlessly politicized, what it refers to—quoting the World Health Organization—is simply a system in which “all individuals and communities receive the health services they need without suffering financial hardship.” Ours is still a patchwork system, but it’s a system that Americans are increasingly committed to protecting. In late February, as congressional Republicans were readying their “repeal and replace” bill, the ACA reached its highest approval level ever: 54 percent, according to the latest Pew Research Center poll.

By now, it’s clear that the Republicans’ new American Health Care Act (contained in two bills, one from the House Energy and Commerce Committee, the other from the Ways and Means Committee) takes us in nearly the opposite direction. While it keeps some important features of the ACA—the requirement that insurers cover 10 essential services, the ban on lifetime-benefits caps—the Republican plan, driven by an outdated free-market mentality that discounts the life-and-death needs of those the market leaves behind, would repeal major provisions of Obamacare that made health insurance for those 20 million people who couldn’t previously afford it a reality. It also leaves the estimated 28 million people who still have no health insurance—mostly in low-income families with at least one worker—without any help at all.

The Republican plan would end the current federal support for Medicaid expansion in 2020, and it would turn Medicaid into a one-size-fits-all program, replacing the open-ended federal payments to states with fixed payments capped per person—which may or may not meet a person’s actual health-care needs. And it would make it impossible for Medicaid recipients to use their insurance at Planned Parenthood, because the legislation bans Medicaid payments to “prohibited entities”—a description tailored in the legislation, without naming it, to Planned Parenthood.

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In addition, the proposed law would end the cost-sharing subsidies that help very-low-income Americans pay deductibles and co-pays. It would replace the ACA’s more generous credits based on need with credits from $2,000 to $4,000 based on age alone, which would only begin to phase out for earners above $75,000. It would burden older people with higher costs: Insurers could charge them five times what they charge younger people, instead of only three times as much under the ACA. People could put more money into health-savings accounts, but these benefit only higher-income people. Obamacare fees that help support health-care expansion would be repealed, such as the taxes on health-insurance companies, manufacturers of brand-name prescription drugs, and high-income earners, who would also get significant tax cuts. And the legislation would eliminate the requirement that larger companies provide their full-time employees with affordable insurance. It would also get rid of the individual mandate, replacing it with a backdoor penalty—a 30 percent surcharge on premiums for anyone who lets their insurance lapse for two months, including people who lose their jobs or who simply cannot afford the premiums.

The Republican House committees introduced—and approved—this legislation in one week, in the absence of official estimates from the nonpartisan Congressional Budget Office of how many people would gain or lose coverage or what the program would cost. In keeping with Trump’s attempts to delegitimize any institution that fails to support his goals, his administration began early on to denigrate the CBO’s competence, fully expecting that its numbers would threaten acceptance of the new Republican bill. And threaten it they did: According to the CBO report, in 2018, 14 million more people would be uninsured under the legislation than under the current law, with that number rising to 21 million in 2020 and 24 million in 2026. By then, an estimated 52 million people would be uninsured, compared with 28 million who would have been without insurance under the ACA. And by cutting an estimated $880 billion from Medicaid funding by 2026, the legislation would also give tax cuts to health-insurance companies and the wealthiest Americans totaling nearly $600 billion.

With a two-year phase-in built into some parts of the legislation, the decimation of health-care access for millions of Americans may take time to be fully felt. But at town-hall meetings and in the streets, Republican lawmakers have witnessed the angry backlash against their disorganized efforts to repeal Obamacare, which has led some prominent Republicans to express grave concerns about the risks to consumers, the insurance industry, and their own political careers. “We’d better be sure that we’re prepared to live with the market we’ve created,” California Representative Tom McClintock was quoted as saying by The Washington Post at a closed-door meeting in January. “That’s going to be called Trumpcare. Republicans will own that lock, stock and barrel, and we’ll be judged in the election less than two years away.”

We cannot know now whether the emerging cross-class coalition of Americans who believe they have a right to affordable health care will hold—whether ordinary people will challenge Republican efforts to protect the wealthy and corporate interests while leaving the poor, near-poor, and struggling middle class to once again fend for themselves. What we do know is that, with the ACA, we took a few small steps into a future inhabited by the rest of the developed world, which sees health care as a right for all. To head back into the bad old days—when empty pockets meant living in terror of an unexpected illness, unrelenting suffering, and an early preventable death—would be nothing if not a national shame.

Angela BonavogliaAngela Bonavoglia, MSW, is a journalist and health communications consultant and the author of Good Catholic Girls: How Women Are Leading the Fight to Change the Church.